Decision Date: 08/01/95 Archive Date:
08/03/95
DOCKET NO. 92-18 328 ) DATE
)
)
On appeal from the decision of the
Department of Veterans Affairs Regional Office in St.
Petersburg, Florida
THE ISSUES
1. Entitlement to service connection for residuals of a
crush injury of the right hand to include arthritis and
carpal tunnel syndrome.
2. Entitlement to a compensable rating for residuals of a
fracture of the right little finger with traumatic
arthritis.
REPRESENTATION
Appellant represented by: The American Legion
WITNESS AT HEARING ON APPEAL
Appellant
ATTORNEY FOR THE BOARD
K. J. Alibrando, Associate Counsel
INTRODUCTION
The veteran served on active duty from December 1942 to
December 1945.
This appeal arises from a January 1992 rating decision which
denied service connection for arthritis of the right hand
and which also denied a compensable evaluation for residuals
of a fracture of the right little finger. A hearing was
held in December 1992 in Washington, D.C. before Donald W.
Datlow, M.D., who was then a member of the Board and who was
designated by the Chairman to conduct that hearing, pursuant
to 38 U.S.C.A. § 7102(b)(West 1991). As Dr. Datlow is no
longer a member of the Board, the veteran was notified in
August 1994 that he was entitled to an additional hearing
before a member of the Board who would render a decision in
his case. In November 1994, the veteran responded that he
did not wish to testify at an additional hearing.
The Board remanded the case in March 1993 for additional
development of the evidence. In part, the RO was instructed
to adjudicate the issue of entitlement to service connection
for a crush injury of the entire right hand, neuropathy and
arthritis and service connection for residuals of a right
shoulder injury to include arthritis. By rating decision in
December 1993, the RO denied entitlement to service
connection for arthritis of the right shoulder and hand and
entitlement to service connection for a crush injury of the
right hand to include carpal tunnel syndrome. A
supplemental statement of the case was issued only with
regard to the rating to be assigned the service connected
fractured right fifth metacarpal and entitlement to service
connection for arthritis of the right hand. Thereafter, in
January 1994, the veteran responded to the Supplemental
Statement of the Case and requested that his records be
forwarded to the Board. By letter to the veteran dated in
February l994, the RO informed him of the denial of service
connection for crush injury to the right hand, carpal tunnel
syndrome and arthritis of the right shoulder and of his
appellate rights. Later that month, a statement was
received by the veteran's representative, noting that the
neurological damage in the veteran's right hand was the
result of his service injury and that his whole hand as
opposed to just a finger was crushed. The undersigned
construes this to be a notice of disagreement to the
December l993 rating action denying service connection for
residuals of a crush injury to the right hand and carpal
tunnel syndrome. Jurisdiction of these issues will be taken
in view of the decision as discussed below. Moreover, it
was not made clear to the veteran in the February l994
letter that he had to file a specific notice of disagreement
if he took issue with the RO's decision regarding the denial
of service connection for arthritis of the shoulder. It is
conceivable that the veteran was under the impression that
this disability was part of that he had already appealed.
Correspondence from the veteran to the Board confirmed that
he wished to appeal the issue of service connection for
arthritis of the shoulder, and he has also raised the
additional issues of service connection for arthritis of the
wrist and elbow. These issues have not been prepared for
appellate review but are inextricably intertwined with the
issue of the rating to be assigned the service connected
finger disability with arthritis. They will be addressed in
the Remand section of this decision, together with the
increased rating issue.
CONTENTIONS OF APPELLANT ON APPEAL
The veteran contends, in effect, that he suffered a crush
injury of the right hand during service. He seeks service
connection for the residuals of that injury which include
arthritis and carpal tunnel syndrome of the right hand.
DECISION OF THE BOARD
The Board, in accordance with the provisions of 38 U.S.C.A.
§ 7104 (West 1991), has reviewed and considered all of the
evidence and material of record in the veteran's claims
file. Based on its review of the relevant evidence in this
matter, and for the following reasons and bases, it is the
decision of the Board that the evidence supports entitlement
to service connection for residuals of a crush injury of the
right hand, to include arthritis and carpal tunnel syndrome.
FINDINGS OF FACT
1. All relevant evidence necessary for an equitable
disposition of the veteran's appeal has been obtained by the
RO.
2. The veteran suffered a crush injury to the right hand in
service.
3. Arthritis and carpal tunnel of the right hand are
attributable to an inservice crush injury to the right hand.
CONCLUSION OF LAW
A crush injury to the right hand, resulting in arthritis and
carpal tunnel syndrome, was incurred in service. 38
U.S.C.A. § 1110, 5107 (West 1991)
REASONS AND BASES FOR FINDINGS AND CONCLUSION
The veteran's service medical records are negative for
complaints, findings or diagnoses of a right hand
disability. The December 1945 separation examination notes
a history of a fracture of the right fifth metacarpal. It
was indicated that a report of this injury was not included
in the service medical records.
In September l978, the veteran filed a claim for service
connection for a back disability. There was no mention of a
right hand disability at this time.
Postservice progress notes dated from March 1958 to November
1977 from John A. Powers, M.D. show that the veteran made no
complaints regarding his right hand and contains no
diagnosis of a right hand disability. Charlotte Memorial
Hospital records dated from April 1958 to February 1959
pertain to treatment for a back disability and contain no
complaints, findings or diagnoses of arthritis of the right
hand. A January 1962 VA final hospital summary shows
treatment for a back disability and is negative for
complaints, findings or a diagnosis of arthritis of the
right hand. VA outpatient treatment records of November
l979 indicate the veteran's complaints of right hand
weakness.
On VA examination of January 1979, the veteran complained of
numbness in his hands. An examination revealed some
decreased sensation about the hands and forearms. The
examiner indicated that the veteran was disabled because of
back, head and neck pain and indicated the possibility of
some mild degree of sensory disturbance of the hands. An x-
ray of the neck revealed degenerative disk disease. The
veteran made no complaints of pain in the right hand, and
there were no findings or diagnosis of arthritis of the
right hand.
In April l989, the veteran filed a claim for residuals of a
right hand fracture.
In September 1989, identical statements were submitted by
J.H. Halsey and George N. Nelms, who reportedly served with
the veteran. Both indicate that they recalled that the
veteran broke his right hand unloading gas drums in 1944.
In September l989, a letter was received from a private
physician. He indicated that the veteran had an old
traumatic arthritis involving the right hand.
In October 1989, the veteran submitted a statement which
indicated that as a result of a fracture of the right hand
in service, he had residual weakness in the hand. Arthritis
developed in that hand in approximately 1958. He asserted
that he received treatment from John A. Powers, M.D. from
1960 to 1980 for arthritis in his hand, receiving injections
and prescriptions.
In January 1990, the veteran testified at a hearing before
the RO that during service, a drum rolled onto his right
hand and crushed it. He stated that the hand swelled and
the fingers of the hand were bruised. He indicated that
medics placed a splint on the hand which remained in place
for 6 to 7 weeks. He stated that he thought an x-ray was
taken at the time of the injury. The veteran testified that
in 1958, he complained of right hand pain to his physician,
Dr. Powers, and that Dr. Powers indicated the presence of
arthritis in the hand. The veteran stated that Dr. Powers
was deceased and medical records pertaining to that
treatment were not available. The veteran reported that
currently, he suffered from continuous right hand pain. He
indicated that swelling occurred with overuse of the hand.
He stated that that he had decreased movement of the fingers
and difficulty opening bottles, tying his shoe and writing
with that hand.
In an April 1990 statement, the veteran asserted that the
right hand was x-rayed in service following the injury,. and
that the x-ray revealed that the hand was fractured. The
veteran also contended that a cast was placed on the right
hand after the removal of the splint. He asserted that he
was seen by Dr. B.L. Black in Charlotte, North Carolina
approximately one year after discharge from active duty for
complaints of right hand pain. The veteran indicated that
Dr. Black prescribed pain medication and felt that the right
hand would remain weaker than the left. He stated that Dr.
Black was deceased and his medical records were not
available.
On VA examination of January 1991, the veteran complained of
continuous pain and weakness of the right hand due to
arthritis. He reported that in October 1944, a drum fell on
his hand, bruising the middle and ring fingers and
fracturing the fifth metacarpal. A January 1991 x-ray
report noted a deformity of the right fifth metacarpal bone
probably from previous injury with no residual fracture
seen. There was some mild subluxation of the proximal
phalanx of the fifth metacarpal bone. There was a small
fragment which was well corticated projecting over the ulnar
styloid which the radiologist indicated might be a sequela
of an old injury. There were some calcifications within the
triangular cartilage and some narrowing of the distal
interphalangeal joints associated with hypertrophic changes.
The radiological impression included evidence of an old
healed injury as described. The examiner indicated that x-
rays showed degenerative changes in the little finger and
that the other digits appeared disease free. The assessment
included some evidence of limited range of motion only on
active trial of his small, ring and middle fingers of his
right hand. The examiner noted that that veteran had a full
passive range of motion, and it was difficult to fully
assess why the veteran had limitation in the active phase.
On VA examination in December 1991, the veteran reported
that a drum rolled on his hand in October 1944. He
indicated that an x-ray taken at the time of the injury
showed a fifth metacarpal fracture which was treated with
cast immobilization for eight weeks. He complained of loss
of sensation in the little finger and loss of function of
his right hand. He stated that shaking hands was difficult
due to pain. On examination, the examiner noted that the
veteran wore a cock-up volar splint. The examiner indicated
that he reviewed x-rays taken in January 1991 of the right
hand which demonstrated evidence of an old fifth metacarpal
fracture, healed in approximately 30 degrees of apex dorsal
angulation at about the mid to distal third. The impression
was old right fifth metacarpal fracture, healed, with 30
degrees of apex dorsal angulation. The examiner indicated
that the veteran resisted active range of motion which was
difficult to correlate with other parts of the physical
examination.
In December 1992, the veteran submitted a copy of a picture
he contends was taken in April 1945 showing that his right
hand was bandaged. A review of the picture by the
undersigned reveals the veteran to be seated with his hands
on his foot and leg. The fingers show no bandages. There
is a white stripe which appears between the veteran's fourth
and fifth fingers, which may be the veteran's sock. The
veteran also submitted an x-ray taken in 1992.
VA outpatient records dated from November 1991 to May 1992
show that in November 1991, the veteran complained of pain
in the dorsum of the right hand and all joints, an inability
to flex the long, right and small fingers and decreased
sensation in all fingers. On examination, there was full
range of motion of all joints with a slight deformity of the
right fifth metacarpal noted. There was active range of
motion of the long, ring and small finger. The examiner
indicated that an x-ray showed 30 degree angulation of the
fifth metacarpal with degenerative joint disease. A
November 1991 electromyogram showed right carpal tunnel
syndrome.
A May 1992 initial consultation report submitted by Vidya S.
Jain, M.D. shows that the veteran reported that his right
hand was crushed in 1944 with injury to the fifth
metacarpal. He indicated continual pain since that injury.
On examination, the veteran had tenderness over the right
little finger metacarpal head. There was no visible
deformity. X-rays revealed that the joint space was
narrowed with some destruction of the bone secondary to
arthritis. The examiner indicated that the veteran had had
a fracture of the fifth metacarpal. He also stated that it
was possible the veteran might have had a contusion of the
nerve at that time which had headed with scarring. The
diagnoses included possible right thumb basal joint
arthritis, generalized osteoarthritis. June to July 1992
treatment records show that that the veteran continued to
complain of right hand discomfort.
A June 1992 report submitted by Shaheda Quaiyumi, M.D. shows
that the veteran reported injuring his right hand in service
in 1944. He indicated he fractured the fifth metacarpal and
also believed that he had injury to the whole hand. He
reported pain and loss of control in the right hand. After
examination, the impressions included osteoarthritis of the
hand secondary to the injury that the veteran suffered
during WWII and possible carpal tunnel syndrome.
On VA examination of May 1993, the veteran reported he had
frequent pains shooting up and down his right upper
extremity from his hand to his shoulder. The examiner noted
that physical examination was very difficult to perform as
the veteran could not relax to allow passive range of motion
testing and seemed to be resisting the examiner throughout
those efforts. The fifth metacarpal of the right hand had a
mild bow dorsally. An x-ray of the right hand showed an old
fracture of the fifth metacarpal and the middle phalanx of
the right little finger, but no other fractures or
malalignment. The radiological impression included no
change in the appearance in the hands since January 1991.
The examiner indicated that x-rays of the right hand
revealed evidence of an old fifth metacarpal fracture with
an angulation of 38 degrees of the distal metacarpal shaft,
otherwise, there was minimal interphalangeal joint
osteophyte formation with preservation of articular
cartilage. The examiner stated that it was extremely
difficult to evaluate the full residual effect of the remote
injury to the right hand due to lack of cooperation by the
veteran during the examination. The examiner concluded
that, based on the radiographs and history, it would not be
expected that the injuries described and visualized would be
as debilitating as they appeared to the veteran.
On VA neurologic examination in May 1993, the veteran
complained of right hand pain since a crush injury in
service. The examiner indicated that an electromyogram and
nerve conduction studies performed in November 1991 revealed
right carpal tunnel syndrome with right medial and sensory
distal latencies prolonged. On sensory examination of the
right hand, there was diffuse sensory pinprick deficit from
the mid forearm down involving the entire hand including the
radial, ulnar and median distribution with no clear
dermatome or peripheral nerve distribution. The impression
was diffuse hand pain of the right hand secondary to a crush
injury with electromyogram and nerve conduction evidence
suggestive of carpal tunnel syndrome, severe without a clear
clinical identifiable and localizing peripheral neuropathy.
On subsequent VA neurological examination in July 1993, the
examiner concluded that the veteran had a right carpal
tunnel syndrome which was most likely related to a crush
injury in 1944.
On VA hand examination of July 1993, the veteran complained
of diffuse pain in the hand which the examiner indicated was
difficult by history to determine exactly where the
complaints were relating to. The physician indicated that
the veteran had evidence of an old fifth metacarpal
fracture, radiographically; and on physical examination, 30
degrees of dorsal apex angulation. There was minimal post-
traumatic arthritis at the proximal interphalangeal joint of
the little finger on radiographic examination. It was noted
that the minimal osteoarthritis could be related to the
veteran's prior trauma, although he had similar changes in
the ring, long and index fingers which were apparently
uninvolved with the accident.
In December 1992, the veteran testified that he suffered a
compound fracture of the little finger of the right hand in
October 1944 after a barrel crushed the entire hand. He
stated that he suffered from arthritis of the right hand.
He indicated that he could not move the little finger of the
right hand. He asserted that he received treatment from a
local physician for arthritis of the right hand sometime in
1946. He testified that he attempted to get those records
but was unable to do so because that doctor was deceased and
the records were not available. He also indicated that he
received treatment for arthritis from Dr. Powers in the late
1940's and early 1950's, but he is also deceased and the
records were unavailable.
The veteran's claim is well grounded within the meaning of
38 U.S.C.A. § 5107(a). That is, we find that he has
presented a claim which is plausible. We are also satisfied
that all relevant facts have been properly developed and
that no further assistance is required to comply with the
duty to assist as mandated by 38 U.S.C.A. § 5107(a).
Under the applicable criteria, service connection will be
granted for a disability resulting from disease or injury
incurred in or aggravated by wartime service. 38 U.S.C.A. §
1110. Service connection may be granted for any disease
diagnosed after discharge, when all the evidence, including
that pertinent to service, establishes that the disease was
incurred in service. 38 C.F.R. § 3.303(d).
After a full review of the record, the Board concludes that
the evidence supports the veteran's claim for service
connection for residuals of a crush injury of the right hand
with secondary arthritis and carpal tunnel syndrome. While
the service medical records are negative for evidence that
the veteran suffered a crush injury of the right hand, the
separation examination does note a history of a fracture of
the right fifth metacarpal. The veteran has testified that
he suffered a crush injury to the right hand when a drum
rolled on that hand in October 1944. Lay statements
submitted by two of the veteran's service comrades in
September 1989, indicate that they recalled that the veteran
broke his hand in 1944. The Board finds that the veteran's
testimony is believable that the whole hand as opposed to
just the fifth metacarpal sustained injury. This is
especially so in view of the fact that the hand is a compact
structure and a drum rolling on it would cause injury to the
entire structure as opposed to one metacarpal.
The question now for our determination is whether the
current disabilities of the hand; i.e. namely the arthritis
and carpal tunnel syndrome, are a result of the injury in
service. The medical evidence of record does not show the
onset of these disabilities until many years after service.
However, as noted above, service connection may be
established for disability diagnosed after service when the
evidence establishes that the disease was incurred in
service. Testing performed by the VA in November 1991
revealed carpal tunnel syndrome of the right hand. In July
1991, a VA neurologist reviewed the medical evidence of
record, including the 1991 neurological testing, and
concluded that that veteran had right carpal tunnel syndrome
which was most likely related to a crush injury in 1944.
Also, in a June l992 report, Dr. Shaheda Quaiyumi indicated
that the veteran had arthritis of the hand secondary to the
injury he sustained during World War II. The Board
concludes, on the basis of the testimony of the veteran, the
lay evidence and the medical evidence of record that it is
at least as likely as not that the crush injury of the right
hand, to include arthritis and carpal tunnel syndrome, is
warranted.
38 U.S.C.A. § 5107.
ORDER
Entitlement to service connection for residuals of a crush
injury of the right hand, to include arthritis and carpal
tunnel syndrome, is granted.
REMAND
In view of the grant of service connection for residuals of
a crush injury of the right hand, to include arthritis and
carpal tunnel syndrome, the Board finds that the issue of a
compensable evaluation for residuals of a fracture of the
right little finger with traumatic arthritis must be
returned for the RO to determine the proper rating for the
hand disability. Moreover, the issues of service connection
for the right wrist, elbow and shoulder are inextricably
intertwined with the issue of the rating to be assigned the
hand and must be adjudicated in connection thereof. In this
regard, arthritis of multiple joints may be rated in
combination. The veteran has filed a notice of disagreement
with regard to the shoulder issue (See the Introduction
section of this decision for a discussion of this matter)
and a supplemental statement of the case must be issued.
Moreover, initial adjudication of the issues of service
connection for right wrist and elbow arthritis must be
accomplished.
Accordingly, the case is REMANDED to the RO for the
following:
1. The RO should adjudicate the issue of entitlement to
service connection for arthritis of the right wrist and
elbow. The veteran should be notified of this decision and
of his appellate rights. If a notice of disagreement is
filed, a supplemental statement of the case should be issued
and the veteran informed of the need to file a substantive
appeal to this issue if he desires to pursue it before the
Board. The RO should also issue a supplemental statement of
the case on the issue of service connection for a right
shoulder disability and afford the veteran an opportunity to
file a substantive appeal. Thereafter, appropriate
appellate procedures should be followed.
2. When the above matters are resolved, the RO should
determine the appropriate rating for the veteran's service
connected residuals of a fracture of the right little
finger, in light of the grant of service connection for
residuals of a crush injury of the right hand, to include
arthritis of the hand and carpal tunnel syndrome. Any
additional examinations deemed necessary should be ordered.
If the decision on the rating to be assigned remains adverse
to the appellant, he and his representative should be
afforded a supplemental statement of the case, to include
all pertinent legal and regulatory criteria and afforded a
reasonable opportunity to respond. Thereafter, subject to
current appellate procedures, the case should be returned to
the Board for further appellate consideration.
I.S. SHERMAN
Member, Board of Veterans' Appeals
The Board of Veterans' Appeals Administrative Procedures
Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740,
___ (1994), permits a proceeding instituted before the Board
to be assigned to an individual member of the Board for a
determination. This proceeding has been assigned to an
individual member of the Board.
NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West
1991), a decision of the Board of Veterans' Appeals granting
less than the complete benefit, or benefits, sought on
appeal is appealable to the United States Court of Veterans
Appeals within 120 days from the date of mailing of notice
of the decision, provided that a Notice of Disagreement
concerning an issue which was before the Board was filed
with the agency of original jurisdiction on or after
November 18, 1988. Veterans' Judicial Review Act, Pub. L.
No. 100-687, § 402 (1988). The date which appears on the
face of this decision constitutes the date of mailing and
the copy of this decision which you have received is your
notice of the action taken on your appeal by the Board of
Veterans' Appeals. Appellate rights do not attach to those
issues addressed in the remand portion of the Board's
decision, because a remand is in the nature of a preliminary
order and does not constitute a decision of the Board on the
merits of your appeal. 38 C.F.R. § 20.1100(b) (1994).
Under 38 U.S.C.A. § 7252 (West 1991), only a decision of the
Board of Veterans' Appeals is appealable to the United
States Court of Veterans Appeals. This remand is in the
nature of a preliminary order and does not constitute a
decision of the Board on the merits of your appeal. 38
C.F.R. § 20.1100(b) (1994).
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